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Leadershipofsensemakingforprimaryhealthcarechanges:LessonsfromtheMitchellsPlainsub-district,SouthAfrica

Introduction

PHCfacilitymanagersandfrontlinestaffinfluencehownationalprimaryhealthcare(PHC)policiesareimplementedandservicesdeliveredthroughtheirroutinepractices.TheSouthAfricanhealthsystemhasanautocratichistoryandinheritedsteephierarchies,whichdiscouragedinitiativeandownership.Nowbothareencouragedandinfactareessentialinimprovingservicedelivery.

Asmiddlemanagers,sub-districtmanagersplayacriticalroleinengagingandsupportingPHCmanagerstothinkandworkdifferently,byhelpingthemtomakesenseofnewPHCpoliciesandtheirrelevanceineverydaypractice,andtotakecollectiveownershipofthesepolicies.

ThisresearchbriefhighlightssomeofthesensemakingactivitiesthathavebeenintroducedinMitchell’sPlainsub-district,andidentifieswhatleadershipofsensemakingentails.

SupportingPHCmanagersthroughaleadershipofsensemaking

Sensemakingis“theprocessindividualsundertakeastheytrytounderstandwhatisgoingonaroundthem,astheytrytomakesenseofeventsandexperiences”.ForPHCmanagersandfrontlinestaff,centrally-ledpoliciesorinitativesabouthowtostrengthenPHCmustmakesensetothemiftheyaretobeincorporatedintotheireverydayroutinesandpractices.Thisincorporationisneededforeffectiveimplementation.

InMitchell’sPlainsub-district,inasituationofmultipledemandsandchallenges,PHCmanagersandfrontlinestaffsometimesdemonstratepassivityintheirroles,andmaybeunwillingtotakeonnewrisksandresponsibilities.Thesebehavioursmayinfluenceimplementation,perhapsevenworkingagainstthegoalsofpolicyreformsaimedatbettermeetingpopulationhealthneeds.ThesechallengeswereidentifiedthroughtheDIALHSlearningsite,andactivitieshavebeenplannedandimplementedtoaddressthem.

TheDistrictInnovation,Action&LearningforHealthSystemsDevelopment(DIALHS)isacollaborativeprojectoftheHealthPolicyandSystems&HealthEconomicsDivisionsoftheUCTSchoolofPublicHealthandFamilyMedicine,theSchoolofPublicHealthatthe

UniversityoftheWesternCape,theCityofCapeTownandtheWesternCapeDepartmentofHealth.Forfurtherinformationcontact:Lucy.gilson@uct.ac.za

DIALHS Policy Brief

15

November 2016

Activitiestopromotesensemaking:examplesfromtheDIALHSlearningsite

Sub-districtmanagershaveinitiatedvariousactivitiesintendedtoprovidespacesofcollectivesensemakingforPHCmanagers,toencouragethemtotakeownershipandoftheirperformanceandthatoftheirstaff.Theseactivities,somedeliberateandothersspontaneous,havecentredaroundsupportingfrontlinestafftomakesmallchangestotheirroutines.

• OneactivitywasanewcommunityprofilinginitiativetoaddressthefrustrationofPHCfacilitymanagersthattheydidnotknowthecommunitiestheywereserving.Workshopsbetweenhealthauthoritiesandcivilsocietyencouragedconversationsaboutlocalhealthneedsandresourcesamongdifferentstakeholders,whichhassinceledtojointhealthinitiativessuchastacklingenvironmentalhealthproblemsinsomecommunities.

• Anotherrevolvedaroundkeyperformanceareas(KPAs),wherePHCmanagersweresupportedtodeveloptheirownobjectives,activitiesandoutcomeswheretheywereheldaccountableforimplementingagreedactions.

• AseeminglysimpleactionofchangingthenameofthePerformanceDevelopmentReviewmeetingstoManagementandCommunication,movedthetop-downapproachtomoreactiveengagementofstaff.Usingroundstoalloweachpersontogiveinput,rotatingthemeeting’schairandaskingchallengingquestionsdemonstratedequality.Thishasallowedspaceforjointreflectiononfacilitychallengesandsharingofbestpractices,improvedteamworkandconstructiveaccountability.

• Sub-districtmanagersarerolemodellingsystematicapproachestomanagementbybeingontimeformeetingsandrespectfultocolleaguesandcoachingstaff,whiletheresearchteamhavemodelledreflectivepracticethroughtheirownapproachtomanagingmeetings.

Conclusion

Middlemanagers,locatedbetweenthecentreandtheservicefrontline,haveavitalroletoplayinprovidingaleadershipofsensemakinginordertosupportPHCmanagerstotakeownershipofvisionsaboutPHCstrengtheningandincorporatethemintotheirdailypractices.

Sensemakingactivitiesareoftenconcernedwithmakingsmallchangesthatcanbeeasilyacceptedandimplemented,butthathavearippleeffectinthehealthsystemandgeneratelonger-termandlarger-scalebenefits.

Toeffectivelysupportorganisationalsensemaking,middlemanagersmustbeabletoreflectontheirownperspectivesandbehaviours,thinkingabouthowtheywillhelpothersthroughchange.Todothis,theyneedtocreatespacesforconversation,reflectionanddialogue,anddevelopsharedinterpretationsandmeaningsofchange.

AuthorsThisbriefwasbasedonthearticles:

• Crises, routines and innovations: the complexitiesand possibilities of sub-district management, SouthAfrican Health Review, 2012-2013, Health SystemsTrust

• Advancing the application of systems thinking inhealth: South African examples of a leadership ofsensemaking for primary health care, 2014, HealthResearchPolicyandSystems,12:30

TheauthorsthankcollaboratorsoftheDIALHSprojectinMitchells’Plain,thefacilitymanagersandparticipatingstaff,aswellasmembersoftheDIALHSresearchteam.ThisworkwasfundedbytheAtlanticPhilanthropies.

DIAHLSisaRESYST-relatedproject.RESYSTisfundedbyUKaidfromtheDepartmentforInternationalDevelopment.However,theviewsexpresseddonotnecessarilyreflectthedepartment’sofficialpolicies.

Elementsofsensemakingleadership

Byreflectingontheactivitiesundertakeninthelearningsite,fiveelementsofleadershippracticesthathelptosupportPHCmanagershavebeenidentified.

1. Theimportanceofmiddlemanagers’personalvaluesasafoundationforotherleadershipactionLeadershipvaluesandcapabilitiesofparticularrelevancetosensemakingforPHCinclude:concernforthepopulationbeingserved,recognisingthepotentialinotherpeople,andbeingreflectiveandwillingtochangeone’sownpractices.

2. NurturingthevalueandmoralpurposeofPHCstaffMiddlemanagersconstantlyandconsistentlyaffirmtheimportanceofpatientsandthebroaderpopulationintheirengagementswithstaff,forexamplebyencouragingfacilitymanagerstorespondspeedilytopatientcomplaints.

3. BuildingrelationshipsandsupportingthedevelopmentofsharedmeaningsaboutchangeCreatingspacesandprocessesthatbringPHCmanagerstogether,andwithotherlocalactors,enablesthemtoshareknowledgeandideas,challengeandlearnfromeachother.

4. Instillingacultureofcollectiveinquiryandmutualaccountabilitywithinthesub-districtMeetingpracticesthatallowmoreactiveengagementandownershipbyallthosepresent,forexamplebyrotatingthetaskofcharing,canprovideopportunitiestodevelopnewformsofaccountabilityandasharedunderstandingaboutwhatenablesandpreventsprogress.

5. RolemodelmanagementpracticesSub-districtmanagersmodelmoresystematicapproachestomanagementthroughtheirpersonalpractices,forexamplebybeingontimeformeetingsandrespectfulintheirtreatmentofcolleagues.